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There's a cancer-related epidemic in the United States and it doesn't have to do with cell growth: doctors are unnecessarily screening the elderly for the disease.
Between a third and half of older patients with a limited life expectancy are undergoing routine cancer screening — despite unproven or limited benefit and the fact that most cancer-screening guidelines suggest avoiding routine testing in patients near the end of life. Researchers published the new data in the Journal of the American Medical Association on Tuesday.
"This adds to a growing body of evidence that some screening tests are being used in circumstances in which the harms likely outweigh the benefits," said Dr. Michael LeFevre, chair of the US Preventive Services Task Force. It also provides yet more proof that we need to curb unnecessary cancer-screening since it's a well-documented source of waste in the over-taxed American medical system.
Elderly undergo dozens of unnecessary screenings
In this study, researchers looked at the rates of cancer screening in more than 27,000 elderly patients (65 years and older) from the National Health Interview Survey over a ten-year period. They grouped the individuals by risk of dying within nine years: a low mortality risk was defined as less than a 25 percent chance of dying within the period, while a very high risk was 75 percent or more.
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(Chart courtesy of JAMA)
Overall, they found 64 percent of the patients had been recently screened for prostate cancer, 63 percent had been screened for breast cancer, 57 percent were screened for cervical cancer, and 47 percent were screened for colorectal cancer.
"These results raise concerns about overscreening in these individuals, which not only increases health care expenditure but can lead to patient net harm," the study authors warned. "A substantial proportion of the US population with limited life expectancy received prostate, breast, cervical, and colorectal cancer screening that is unlikely to provide net benefit."
Too many prostate-cancer tests
They found that even groups of people who were likely to die within a short period of time were getting screened. For example, 55 percent of elderly men who had a life expectancy of five years underwent routine testing for prostate cancer.
The best-available evidence suggests routine PSA-testing causes over-diagnosis of tumors that will never lead to deadly cancers and that more elderly men will die with and not from prostate cancer. For this reason, the American Society of Clinical Oncology, the American Cancer Society, and the American Urological Association all recommend stopping prostate-specific antigen (PSA) screening in men who are expected to live less than ten years. The United States Preventive Task Force even recommends against routine PSA testing for all men since the potential harms related to over-treatment outweigh the benefits.
One of the main problems with prostate screening in older men, said Dr. Richard Ablin, a professor of pathology at the University of Arizona, is that it sets patients on a pathway of unnecessary treatment that will diminish their quality of life for no benefit. "We know you're probably going to be better off not doing anything in these people because their quality of life after treatment with surgery or radiation is going to be so poor, that in many cases they'd be better off if they weren't treated at all."
Cervical smears being done in women without cervixes
Elderly women who had their cervix removed in hysterectomies were being screened for cervical cancer with Pap tests. (Between 34 and 56 percent of these women got a Pap test anyway.) Again, most medical guidelines suggest stopping routine Pap tests in older women, particularly those who have undergone hysterectomies and have no history of cervical cancer. "Nobody has recommended Pap smears on women who have had a hysterectomy for anything other than cervical cancer," said Dr. LeFevre. "And yet people are still getting them and that's disappointing."
Among patients with the shortest life expectancies (about five years), 40 percent had been screened for colorectal cancer. The American American College of Physicians, meanwhile, recommends against screening in people with less than 10 years to live.
"The preparation for a colonoscopy in an older person may not be an easy thing to do and can be quite debilitating because you need the clean the colon out," said Dr. Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. There's also procedural risks of a biopsy gone wrong, which include bleeding and perforation. "Then there's the chance that if you find cancer and operate on it, it wouldn't help them anyway because they are going to die from something else, their near term death risk is so high."
Advice for elderly patients
Dr. Welch's advice to patients is that they need to remember that screening is a double-edged sword. "Older patients will be exposed to the harms of screening and those harms are near-term but they can't experience the benefits since those benefits will happen in the long term."
Dr. LeFevre also said patients should not assume that all screening tests are going to be helpful. "When the issue comes up in the context of their health care, it's very fair to ask, 'What is the likelihood I'm going to benefit form this test?' and 'What's the likelihood I'm going to be harmed?"
